The natural history of postischemic T-wave inversion: a predictor of poor short-term prognosis?

BACKGROUND: This study followed up the natural history of T-wave inversion and assessed the short-term prognosis associated with the condition. METHODS: Forty patients with acute ischemic syndrome, without infarction, and with postischemic T-wave inversion (group 1) were followed during the persistence (inverted T-wave period) and after the resolution of T-wave inversion (positive T-wave period). Another 40 patients with acute ischemic syndrome, without infarction and with normal T waves (group 2), were also followed. RESULTS: Postischemic inverted T waves showed resolution within 3-21 days of presentation in 31 patients from group 1 on medical treatment alone. Further ischemic events (acute myocardial infarction, acute ischemic syndrome, angina pectoris, silent ischemia), inducible ischemia (during treadmill test), wall-motion abnormalities (demonstrated by echocardiography), all developing in the primarily ischemic myocardial area, were more frequent (P < 0.02) in group 1 patients during the inverted T-wave period compared with those experienced in the positive T-wave period of group 1 patients, and compared with group 2 patients. CONCLUSION: In most patients on medical treatment, postischemic inverted T-waves tended to resolve within 3 weeks. The presence of postischemic inverted T waves appears to be an independent marker of further ischemic events.

Emergency percutaneous transluminal coronary angioplasty without thrombolysis as initial therapy in acute myocardial infarction.

Thrombolytic treatment in acute myocardial infarction does not influence the atheromatous coronary lesions which form the basis of thrombosis. The remaining stenosis may be responsible for recurrent ischemic symptoms or reinfarction. Percutaneous transluminal coronary angioplasty without thrombolysis was attempted in 19 anterior and 24 inferior wall acute infarctions, within the first 4 hours from the onset of symptoms. The aim was to achieve optimal myocardial revascularization and prevent reocclusion of the infarct-related vessel. Significant stenosis or complete occlusion was found in only one major coronary artery in 25 patients, in two arteries in 7 patients and in three in 11 patients. Angioplasty was only applied to the vessel supplying the infarcted muscle. Recanalization was achieved from 14 to 50 minutes (mean 23) from the start of catheterization in 95% (41/43 cases). Two of the patients died in cardiogenic shock. Four patients died between days 5 to 15 of hospitalization. There were no other deaths. Thirty (81%) of the 37 survivors remained asymptomatic, 3 required bypass surgery for recurrent angina. Follow-up hemodynamic studies were done on average 2.5 months after angioplasty, and showed that, in 78%, the dilated coronary artery remained patent. Restenosis was found in five patients, and was successfully dealt with using angioplasty in three cases. In those patients with improved segmental wall motion, the global left ventricular function also increased. This applied to both anterior and inferior infarcts. Our results suggest that immediate coronary angioplasty in acute impending myocardial infarction is effective and avoids the need for prior thrombolytic therapy.

The combined use of diastolic counterpulsation and coronary dilation in unstable angina due to multivessel disease under unstable hemodynamic conditions.

Sixteen patients with multivessel ischemic heart disease and severely jeopardized myocardium required intra-aortic balloon counterpulsation subsequent to a deterioration in hemodynamics during or following a coronary angioplasty procedure. They had all suffered unstable angina which was refractory to intensive medical therapy, consisting of a combination of nitroglycerin, beta-adrenergic antagonists, and calcium blockers. Thirty angioplasties had been attempted (1.9 artery stem/patient) with a primary success rate of 90%. The symptoms of prolonged myocardial ischemia had disappeared, and the patient's blood pressure had normalized. No complications were associated with the use of the mechanical circulatory assistance. There were no deaths related to the procedure itself, and no myocardial infarctions. Emergency surgery was not required. One patient did die in hospital, however, due to cerebrovascular accident which occurred 4 days after removal of the mechanical circulatory support. Two also died suddenly later. One patient also required later elective coronary arterial bypass surgery and another needed repeated coronary dilation. The 12 remaining patients are asymptomatic at a follow-up with mean value of 22 months. Temporary intra-aortic diastolic counterpulsation is a useful adjunct to coronary angioplasty in patients with multivessel unstable angina and compromised hemodynamics.

Autonomic sinus node dysfunction and its treatment.

The clinical, electrocardiographic, pharmacologic, electrophysiologic and Holter monitoring findings are described in four patients with autonomic sinus node dysfunction and one patient with autonomic binodal disease. All showed cerebral symptoms, and had attacks of dizziness, weakness, near-syncope or syncope. After a pharmacologic autonomic blockade with propranolol and atropine, all patients had normal intrinsic heart rates. Electrophysiological studies revealed normal corrected intrinsic node recovery time (less than or equal to 240 msec) a gradual return to the basic cycle length in the secondary postpacing cycles after autonomic blockade, and no intrinsic paroxysmal atrioventricular block. Continuous ECG monitoring (1-3 X 24 hours) revealed severe sinus bradycardia, SA-block, severe sinus arrest, cardiac standstill, atrial fibrillation and in two patients associated AV-block. Autonomic blockade with electrophysiological studies exclude the intrinsic involvement of the sinoatrial and atrioventricular node. Holter monitoring is the best method for assessing the autonomic neurovegetative component of dysrhythmias. Therapy regarding isolated autonomic sinus node dysfunction depended on the pathomechanisms of rhythm disorders: two patients received permanent pacemakers, antiarrhythmic drugs were applied in the case of two patients, and etiological treatment in the case of one. During the follow-up, all patients became symptom-free.

Holter monitoring in the complex analysis of sinus node dysfunction.

To study the diagnostic possibility and the mechanisms involved in sinus node dysfunction, 23 patients with sick sinus syndrome were evaluated by the basic electrophysiological method (recovery times, secondary postpacing phases, sinoatrial conduction times) before and after pharmacologic autonomic blockade with i.v. propranolol 0.2 mg/kg and atropine 0.04 mg/kg, and by continuous rhythm monitoring. Patient groups of normal (I) and pathological (II) intrinsic heart rate (IHR) were compared. In group I (no. 15) prolonged recovery time (2/15), postpacing sinoatrial-block (1/15) and chaotic postextrasystolic patterns (5/15) ceased after autonomic blockade; we obtained normal intrinsic recovery time, gradual return to the stable intrinsic sinus cycle length in the secondary phase, and a normal intrinsic sinoatrial conduction time. In group II (no. 8) during the control study only 50% of patients had pathological electrophysiological parameters before, and 100% after the drug test (no gradual postpacing return to the intrinsic heart rate, abnormal recovery times, abnormal sinoatrial conduction times or chaotic postextrasystolic patterns). Holter monitoring revealed significant differences between the minimal heart rate during sleeping (group I: 48 +/- 10 bpm, mean +/- SD group II: 32 +/- 4 bpm, probability less than 0.001) as well as in the average sinus cycle length for 24 hours (group I: 848 +/- 88 ms, group II: 1254 +/- 136 ms, P less than 0.001) with a very characteristic histogram. In the patients with pharmacologically and electrophysiologically documented abnormal intrinsic rhythmicity (group II), the first 24 hour Holter monitoring revealed positive ECGs for sinus node dysfunction. In patients with normal intrinsic electrophysiological sinus node properties (group I) repeated continuous rhythm recordings revealed severe sinus bradycardia (1 patient), sinoatrial-block (1 patient), tachybrady syndrome (1 patient) and sinus-arrest (2 patients, up to 29 120 ms in waking period). These findings suggest that 1) IHR is the best and simplest diagnostic method of intrinsic sinus node dysfunction (in patients of abnormal low IHR we found positive electrophysiological and Holter parameters), and 2) in autonomic sinus node dysfunction electrophysiological parameters are essentially negative showing normal intrinsic sinus node function; in these patients systematically repeated Holter monitoring is the most valuable diagnostic method.

Synchronized and desynchronized sinus node activity.

In certain cases because of sinus arrhythmia and/or anarchic return and postreturn cycles caused by premature atrial stimulation, the sinoatrial conduction time cannot be calculated since a chaotic postextrasystolic pattern appears. We examined 49 patients with a history and ECG signs suggesting sinus node dysfunction by programmed extrastimulation method as proposed by Strauss et al. prior to and after pharmacologic autonomic blockade (with propranolol 0.2 mg/kg body weight and atropine sulfate 0.04 mg/kg intravenously). Patients with normal intrinsic heart rate (IHR) (n = 31) showed chaotic postextrasystolic responses in 38%, which in every case could be eliminated by autonomic blockade, resulting in a clear I and II phase with a well estimated intrinsic conduction time. Patients with pathologic IHR (n = 18) gave chaotic responses in 22% which after drug testing increased up to 72%. The chaotic postextrasystolic patterns are to be interpreted as the desynchronization of the sinus potentials, while plateau (phase II) as functional integrity, synchronized activity of the sinus node, dependent on the momentaneous balance of the autonomous tone, and on the integrity of the pacemaker cells. The desynchronized chaotic responses are considered on one hand as a dystonic neurovegetative electrophysiologic characteristic, on the other hand as a primary extrastimulation parameter of the intrinsic sinus node dysfunction.

[Sinoatrial and intra-atrial conductive disorders. The value of recording the sinus node potential]. / Troubles conductifs sino-auriculaire et intra-auriculaire. Intérêt de l'enregistrement du potentiel sinusal.

Direct recording of the sinus node potential in the bipolar mode using two electrodes of a quadripolar recording catheter positioned in the region of the sinus node at the junction of the superior vena cava to the right atrium was performed in 24 patients. Asynchronous overdrive atrial pacing was carried out using Strauss 'technique. Pharmacological denervation was carried out using intravenous propranolol (0,02 mg/kg) and atropine (0,04 mg/kg) using Jose's technique. An intravenous injection of a bolus of 20 mg of ATP was given in 3 cases. The sinus potential was identified by morphological criteria and confirmed after carotid sinus compression and atrial extrastimuli to exclude artefacts, especially the end of ventricular repolarisation of the preceding complex. The sinoatrial conduction time measured directly under basal conditions was considered normal when within 80 to 150 ms. Direct measurement of the sinus potential in the diagnosis of sinus node dysfunction seems to be less useful than the indirect techniques. On the other hand, it does confirm the diagnosis of sinoatrial block: five cases of special interest are described; in four cases the degree of sinoatrial block was variable: a significant increase of sinoatrial conduction time under basal conditions in 1 case; paroxysmal 3rd degree sinoatrial block revealed by programmed atrial stimulation in 2 cases; 2nd degree 2/1 sinoatrial block after injection of ATP in which the direct sinoatrial conduction time and sinus node function had been considered to be normal (1 case).(ABSTRACT TRUNCATED AT 250 WORDS)

[Emergency and elective percutaneous recanalization in ischemic heart disease]. / Azonnali és tervezett percutan rekanalizáció ischaemiás szívbetegekben.

The success and complication rates of programmed angioplasty performed after diagnostic coronarography and of ad hoc angioplasty performed at the time of the diagnostic catheterization are analysed in the study. We have attempted percutaneous recanalisation of 1071 lesions on 440 patients and dilated an average 2.4 stenoses or occlusions by patient. Immediate intervention was performed on 59.5% of patients with overall 91.7% success rate. The need for emergency surgery was 0.7%, periprocedural myocardial infarction was observed in 1.5%, and the mortality rate was 1.5%. The success and complication rates were similar for both studied groups. In the ad hoc angioplasty group there were relatively more easily solvable cases concerning the techniques, however the incidence of unstable angina and acute, emergency settings were more frequent. Ad hoc angioplasty does not diminish the success rate and resulted a faster, and more spectacular recovery in the above severe cases. Extensive experience with ad hoc angioplasty has proven it to be reasonable approach, efficient and safe variation not only in rescue, but also in complex angiological settings, if the considerable logistics are possible in an individual cardiovascular center. The provision of ischaemic heart disease patients is subject to the planning and creating such anti-ischaemic interventional cardiological centers in Hungary.

[Hemodynamic effects of verapamil in pulmonary hypertension caused by heart valve disease]. / Verapamil haemodinamikai hatásainak vizsgálata billentyübetegségek kapcsán kialakult pulmonalis hypertoniában.

The authors have investigated the haemodynamic effects of verapamil on the pulmonary circulation by 24 patients suffering from secondary pulmonary hypertension, caused by mitral and/or aortic valve diseases. For this purpose the numeric and graphometric analysis of intracavitary right ventricle pressure curve and pulmonary artery pressure tracing was applied. It was observed a selective antihypertensive effect on the lesser circulation. The pulmonary and systemic systolic tension decreased comparing in percentage 3:1, in case of diastolic tension this comparison was 2:1. The decrease in pulmonary circulation was strongly significant. The diminishing of heart rate and the improving of right heart function was not significant. The elevation of end-diastolic pressure of the right ventricle, just as the shape-analysis of pressure curves suggested right ventricle overload.

[Use of coronary vessel prosthesis. Complex coronary angioplasty under general anesthesia]. / Koszorúér-protézisek alkalmazása. Altatásban végzett komplex coronaria angioplasztika.

In 1995 we attempted to treat with PTCA 437 ischemic patients. We stended 29 patients (6.6%) with 34 stents. Emergency stenting was done in 5, semi-elective stenting in 6, and elective stents were applied in 18 patients with restenosis. We have achieved good angiological results without occurrence of myocardial infarction, with no emergency open heart surgery or death. No intracoronary thrombosis was observed during one-month follow-up with combined aspirin and ticlopidin treatment. Hemodynamical and angiological high-risk patients were treated under general anesthesia with assisted respiration. No complications were observed during the procedures. In cases of in-stent restenosis (17%) we redilated the coronary artery. This technique proved to be promising and is routinely applied world-wide to optimise immediate and long-term results of PTCA. The realisation of such interventional cardiological centers with appropriate financial background is an absolute requirement for spreading this technique in Hungary.

[Postischemic inverted T waves: does gradual regression indicate improved prognosis?]. / A postischaemiás invertált T hullámok természetrajza: a fokozatos megszünés javuló prognózist jelent?

This study has followed up the natural history of postischemic inverted T waves and assessed the prognosis. 40 consecutive patients with unstable angina with postischemic precordial inverted T waves in the noninfarcted, previously ischemic area were followed during the persistence (negative T wave period) and after resolution of inverted T waves (positive T wave period). The outcome with frequencies of acute myocardial infarction, acute ischemic syndrome, angina pectoris, positive exercise test, silent myocardial ischemia, anterior wall motion abnormalities on echocardiogram, positive coronary arteriography were determined and compared in the negative versus positive T wave periods. Postischemic inverted T waves showed resolution within the postischemic 3-21 days (at a mean of 10.6 days) in 31 patients on medical treatment alone during the whole study period. Frequencies of parameters/patients determined in negative versus positive T wave periods are as follows: acute myocardial infarction: 5/40 versus 0/31 (non significant), acute ischemic syndrome: 25/40 versus 2/31 (p < 0.001), angina pectoris: 32/40 versus 11/31 (p < 0.001), positive treadmill exercise test: 14/16 versus 14/30 (p < 0.02), silent myocardial ischemia: 14/14 versus 16/31 (p < 0.01), hypokinesis 26/34 versus 4/24 (p < 0.001), positive coronary arteriography: 4/4 versus 11/11 (non significant). In most patients on medical treatment, the postischemic inverted T waves tend to resolve within 3 weeks. Attention has to be paid to the patients with postischemic inverted T waves during the negative T wave period: the high ischemic risk gradually decreases with resolution of negative T waves.

Autonomic blockade and sick sinus syndrome. New concept in the interpretation of electrophysiological and Holter data.

Autonomic blockade is commonly employed as a test of sinus node dysfunction. We compared primary and secondary atrial postpacing pauses and postextrasystolic sino-atrial responses before and after autonomic blockade in 56 patients with the clinical diagnosis of sick sinus syndrome. Pharmacological autonomic blockade was achieved by atropine 0.04 mg kg-1 and propranolol 0.2 mg kg-1, i.v. In a group of patients with a normal intrinsic heart rate the number of positive electrophysiologic variables associated with sinus node dysfunction declined after autonomic blockade. In 91% of these patients, sinus node function was characterized by a normal intrinsic recovery time, gradual exponential return to the constant sinus cycle length, and biphasic postextrasystolic return responses. Three patients in this group had intrinsic SA-block revealed by atrial pacing and verified by Holter monitoring. Besides normal intrinsic pacemaker properties in 53% of patients, rhythm monitoring revealed severe sinus node dysfunction as manifested by bradycardia and the tachycardia-bradycardia syndrome. SA-block and sinus arrest up to 29120 ms. In the abnormal intrinsic heart rate group, disturbed intrinsic rhythmicity was characterized in all by a prolonged corrected intrinsic recovery time (2320 +/- 2740 ms [+/- SD]), arrhythmia and/or bradycardia in the secondary postpacing cycles, chaotic postextrasystolic patterns, or prolonged sinoatrial conduction times. Significantly slow minimal heart rates during sleep significantly prolonged average sinus cycle lengths and positive ECGs for sinoatrial disorders in the waking period were present on the 24-h rhythm recording. It is concluded that intrinsic heart rate obtained by autonomic blockade is the best and most simple method for the diagnosis of intrinsic sinus node dysfunction. Combined autonomic blockade and electrophysiological tests can be of great value in unmasking the severity and degree of intrinsic dysfunction and analyzing the abnormality of secondary pacemaker function. These investigations, however, are rather insensitive and therefore ineffective in detecting autonomic sinus node dysfunction. To assess the role and significance of the autonomous neurovegetative tone in the genesis of sinoatrial disorders, rhythm monitoring is required.

Autonomic sinus node dysfunction documented by Holter monitoring studies in 21 patients.

Holter recordings were carried out in 21 patients with presupposed sinus node dysfunction (SND). All the patients were evaluated also by complex electrophysiological examinations (overdrive and premature atrial stimulation) before and after pharmacologic autonomic blockade (AB) with propranolol 0.2 mg/kg and atropine 0.04 mg/kg body weight intravenously. Groups of normal and abnormal intrinsic heart rate (IHR) were compared. In patients with normal IHR (n = 13) the prolonged recovery time (5/13), postpacing SA-block (1/13) and chaotic postextrasystolic patterns (4/13) ceased after AB. Intrinsic recovery time became normal with a gradual return to the stable sinus cycle length, and we obtained normal biphasic postextrasystolic intrinsic return responses. In all cases of pathological IHR (n = 8), abnormal intrinsic rhythmicity was verified by electrophysiological means. Holter monitoring revealed significant differences (P less than 0.001) between the minimal HR during sleeping and also in the HR averaged for 24 h between the two groups. In patients with abnormal IHR, the 24 h rhythm recording revealed positive ECG data for SND. In patients with normal intrinsic electrophysiological properties, Holter monitoring revealed severe sinus bradycardia (1 case), SA-arrest (1 case), SA-block (1 case), tachy-brady syndrome (1 case), and atrial fibrillation with AV-block (1 case). For appreciating the role and significance of the autonomic neuro-vegetative tone in SND, continuous rhythm monitoring is necessary.